Guatemala | When Tears Crept Close in Guatemala—reflections on a 4-year-old patient

By: Alexandra Lee

On the school global outreach trip to Guatemala, a particularly difficult patient encounter allowed me to reflect on my fears and anxieties about entering the clinical years of my medical education. In the beautiful town of San Antonio Palopó, which is tucked cliffside along Lake Atitlán, I saw this child. Before our trip, I had brushed up on the common ailments we typically see on global trips—skin rashes, upper respiratory infections, GI complaints.

However, I was in no way prepared for my first patient that day – a four-year-old girl with vaginal bleeding and discharge. I will call her “Luisa.” Her mother told me that she and her husband were splitting up, and Luisa was feeling frightened of her father. Her daughter wasn’t sleeping at night and was drawing disturbing images. She’d become violent, and her behavior was becoming very concerning to her mother. Hearing this history and considering the nature of the chief complaint, I knew sexual abuse had to be considered.

I paused and looked at little Luisa playing with the toy wooden car I had given her. In lectures at school we had talked about sexual abuse, but now I was seeing sexual abuse as a real possibility. Feeling tears welling, I took some deep breaths, finished the rest of the history, and regained my composure. What now? Should I inquire more about the possibility of abuse? Would this be culturally appropriate?

Normally, I would move on to the physical exam, but I was at a complete loss, admitting to myself that I had little-to-no pediatric experience and absolutely no knowledge of pediatric gynecologic issues. I told Luisa and her mother that I wanted to talk with a nearby doctor, and I pulled aside my attending Dr. Jennifer Goodfred. With the patient and her mother, we retreated to a private room where Dr. Goodfred guided me through the exam. No physical signs of abuse were found, and the girl’s symptoms were determined to be the result of a vaginal infection. I sent Luisa home with antibiotics, education on hygiene, and a referral for counseling to help her family cope with some of the domestic trouble resulting from her parents’ break-up.

As our week in Guatemala continued, I kept thinking about my encounter with Luisa. How could I have helped her more? Why did I, a strong, independent woman, become so emotional? Trying to brush off my self-doubts, I told myself that in my third and fourth years, my rotations and residency would thicken my skin. But now I realized that my biggest apprehension about entering clinical rotations was how to maintain professional composure when faced with sadness and tragedy. I had been overwrought with the mere possibility that this child had been abused, even before I did a physical exam. How would I handle death and suffering in my patients in the years to come in my career? Feeling ashamed and embarrassed, I had almost shed real tears in front of patients and my attending physician.

After the trip, I began to reflect on why shame is often the prevailing reaction when a doctor expresses genuine emotion around patients. In an article in the Journal of Palliative Medicine, Helen Gharwan discusses the physician’s grief response in patient care. “Does the feeling of shame not arise from the perception or an awareness of having fallen far from the ideal, of not having been perfect, and of having shown a certain degree of weakness?”1 In a competitive, demanding profession, a doctor’s tears can be seen as a sign of weakness. The image of perfection and composure shrivels, and a doctor may brand herself a personal failure.

In such a situation, I need to remind myself that I am not alone. According to a study on how physicians experience grief, 61% of physicians found deaths of patients too emotionally distressing, 73.1 percent of medical students reported crying, and 16.5 percent reported nearly crying2 in their clinical rotations. Shame at outright expression of vulnerability is a common reaction. Yet I know that what drives my emotion and empathy is what make me human—the very qualities that called me into this profession in the first place. “What kind of physician and what kind of person would I be if I remained indifferent and untouched by my patient’s anguish?”1 Gharwan ponders.

After taking time to reflect on my encounter with Luisa, I found some peace of mind. I never want to become a doctor who is jaded to the pain and grief of my patients. It was this sense of compassion for the suffering of my patients that enabled me to care for Luisa and her family, to listen closely to her mother’s concerns, and to provide Luisa with the care she needed. While my empathy and emotions may be strong, I hope that this passion will help enable my successful treatment of patients in rotations and in my future as a physician.

Shifting to the patients’ point of view, I asked myself how I would feel if I saw my doctors crying or otherwise revealing their raw emotions. In the situation with Luisa, I feel it was appropriate to hold back my tears especially because we did not know what was really going on or if she was in fact being abused. This was a time where I needed to be strong for my patient. There are other times where I think it is okay to show your vulnerable side, to cry with a patient who has experienced death or loss. I think these nuances and others are something doctors learn over years of practice, and they comprise the art of medicine. Hopefully my clinical rotations will continue the journey of learning that art.

One night during the Guatemalan trip I talked to Dr. Goodfred after dinner, and she shared something I will never forget. After her many years in clinical practice, she said that she still has patients who affect her so deeply and bring her to tears. But these patients drive her to keep practicing in this challenging world of medicine.

While our emotions can be unsettling at times, they remind us of our humanity and inspire us to provide the best possible care to our patients. Medicine will throw some difficult, heartbreaking challenges my way. But I don’t always have to fight my emotions. I can take a deep breath and accept emotion and empathy as companions that are helping to mold me into a better, more compassionate physician.